Nominate a Child

Please note you must fill out the entire form below in order to submit. Once you form is submitted it will be reviewed and we will be in touch.

Which Affiliate Location is nearest to the child's home:

Male or Female

Does the child live at this address permanently?

If no, does the child reside where the bedroom makeover would take place at least 50% of the time?

Are you the owner of the property listed on this application?

Does the child named on this nomination form share a room with his/her sibling?

Is this a chronic or terminal illness?

Important: Publicity is vital to the growth of our organization. It is through publicity that we gain potential donors as well as applicants. The family will be asked to sign a MEDIA consent form if chose for a bedroom makeover. Do you Agree?

IMPORTANT: You may be asked to submit a Healthcare Professional Form, verifying your child's diagnosis. While we know this can hold up an application, we must have one on file before any work is done on the room (if this form is required by the MHP Affiliate). You may submit the actual application asap, but if application is accepted, this form must be completed by the child's healthcare team before any work is done on the room. You may print off this form to take to your child's healthcare provider to have them sign and mailing it to the MHP Affiliate's address or direct the healthcare provider

I confirm that all of the above information is true and correct by submitting this application.

8 + 11 =

Have questions about becoming involved in My Happy Places?

We love answering questions and connecting with you! Whether you are interested in volunteering, becoming a sponsor or partner, or even potentially becoming an affiliate,
you can contact us today and we will get back with you shortly.

HOME
ABOUT
BUTTERFLY PROJECT
BECOME A SPONSOR
VOLUNTEER

WANT TO GET IN TOUCH?

We love answering questions and connecting with you! Reach out to us today and we will get back with you shortly.

BECOME A PARTNER
NEWS & STORIES
EVENTS
AFFILIATES
CONTACT